1. Texas Council Update
Presented by: Isabel Casas, Director of IDD Services
Erin Lawler, Director of Healthcare Policy
Texas Council of Community Centers
January 10, 2019

2. Overview Electronic Visit Verification PASRR Lawsuit Update HCBS News
IDD Consortium Business
Legislative Update
HHSC News
Texas Council Workgroup News
NCQA Project
Electronic Visit Verification
PASRR Lawsuit Update
HCBS News
Post-DSRIP Landscape
Managed Care Procurement

3. Legislative Update

4. Important Dates January 8, 2019 March 8, 2019 May 27, 2019
First day of session
House and Senate News
March 8, 2019
Deadline for legislators to file legislation that is not local
May 27, 2019
Last day of session
Two days down, 138 days to go! (Third day of session)
House News: New Speaker, Dennis Bonnen from Angleton (Brazoria County, Gulf Coast Center)
Senate News: Charles Schwertner from Georgetown (Williamson County, Bluebonnet Trails) gave up his chairmanship of the Senate HHS Committee. No one has been appointed.
Fun fact: Senator Jane Nelson from Flower Mound (Denton and Tarrant counties) was the first woman to gavel in a new legislative session.
Lee is going to join us tomorrow to provide more information on what I’ve mentioned and more…so come with your questions! Prize for anyone who stumps him. Jk.

5. HHSC IDD-Related Exceptional Items
$147.7 million in state funds
Provide community services to more than 4,500 persons
4. Interest List Reduction
$70.7 million in state funds
Caseload and Cost Growth
6. ECI Services
$46.4 million in state funds
Prevent and intervene during crises
22. IDD Crisis Continuum of Care
$114.9 million in state funds
Replace Day Habilitation with Individualized Skills and Services
28. HCBS Community Integration Compliance
Also important to IL Reduction is funding cost growth, which put another way funds attrition to waiver programs. This EI includes $28.1 million in state funds, $74.4 AF)
IL EI includes $378.3 million AF (state funds and $230.6 million in federal funds)
IDD Crisis Continuum of Care, which has the backing of the Statewide Behavioral Health Coordinating Council, will
maintain ECC and TST funding set to expire this year. (Stay tuned for more MFP Updates later.)
expand existing crisis respite and intervention services to prevent and intervene in crises.
establish new IDD community outpatient mental health services at local IDD authorities to prevent crises by providing integrated physical and behavioral health services for persons with IDD.
Others:
36. Provide specialty services (wheelchair fabrication, dental, etc) at SSLCs.
38. Allow high-needs HCS consumers who reach the dental cap to access adaptive aide funds ($10,000 cap) to prevent more serious health issues.

6. Statewide IDD Strategic Plan
Recommendation to develop a Statewide IDD Strategic Plan
IDD Gap Survey
Draft Foundational Plan
Seek legislative backing
Complete Statewide IDD Strategic Plan

7. IDD Services Redesign Recap News
Pursuant to SB 7 (2013), state law requires IDD LTSS Waiver services to transition to managed care by 2021.
The IDD SRAC recommends delaying the transition of
TxHmL services for at least three years, and
All other waiver services for at least seven years.
MCOs, led by United Healthcare and Molina, developed a proposal for an IDD Managed Care demonstration, to extend certain CLASS and TxHmL LTSS services to voluntary STAR+PLUS members on and IDD interest list.
Details continue to evolve.
The MCO Pilot/Non-pilot/Demonstration would extend LTSS services associated with the CLASS and TxHmL waivers today (e.g. respite, day habilitation, behavior supports) to a cohort of STAR+PLUS members with IDD currently on IDD Waiver Interest Lists and would not include any residential services.

8. HHSC Update

9. Dr. Courtney Phillips started on October 19, 2018.
New HHSC Executive Commissioner
In October, HHSC released draft rules establishing administrative penalties for certification principle violations and allowing for right to correct, amelioration, and an informal dispute resolution processes.
With input from relevant workgroups and Community Center leadership, Texas Council submitted informal comments on behalf of Community Centers emphasizing the need for interpretive guidance and including clear communication of expectations in the rules as appropriate.
HCS/TxHmL Administrative Penalties Draft Rule
Dr. Evanthe Collins, DSHS/DADS Contract Manager, The Harris Center for Mental Health and IDD, and Jennifer Caruso, IDD Services Business Services Manager, Alamo Area Council of Governments were appointed to the committee.
HHSC IDD SRAC Appointments
In November 2018, HHSC received additional funding from CMS for the Enhanced Community Coordination (ECC) and Transition Support Teams (TST) Money Follows the Person (MFP) initiatives.
MFP funds will now be available through May 2019.
MFP News
Re: HCS/TxHmL Admin Penalties Draft Rule: Pursuant to SB 1385 (2015) and HB 2590 (2017)
Pending MFP Request: HHSC submitted a request to CMS for additional funding to extend ECC and TST through December HHSC will provide an update when CMS makes a decision regarding this request.

10. PASRR PCSP Training HCBS Webcasts
HHSC anticipates adoption of PASRR Habilitation Coordination rules in March 2019.
In preparation for new rules implementation, HHSC is working with the Transition Support Teams (TSTs/hubs) to host two trainings:
PASRR Comprehensive Service Plan (PCSP) Form training (Jan. 2019)
PASRR Habilitation Coordination training (TBD)
HCBS Webcasts
HHSC staff anticipates posting the updated HCBS statewide transition plan (STP) for public comment in mid-January 2019.
State agency staff are working with the TSTs/hubs to host several HCBS webcasts in early February, during the STP comment period.
PCSP Trainings (I have a handout of trainings):
1/11 – Austin, web access available
1/15 – Dallas/Tarrant, web access available
1/16 – Texana, web access available
1/18 – Lubbock, web access available
1/22 – Nueces, no web access available
1/22 – El Paso, no web access available
Sign up is available through HHS’ Learning Portal. TxC sent a communication with sign up information on January 4, 2019.

11. Determinations of Intellectual Disability
Discussion:
Determinations of Intellectual Disability
Earlier this week (on January 7), Texas Council shared statewide data related to conducting Determinations of Intellectual Disability (DIDs), which was provided by HHSC.
Self-reported FY 18 and 19 encounter data indicates several Centers reporting the completion of no, or very few, DIDs.
The communication was intended to not only share the data, but also ask IDD Consortium representatives from all Centers to be prepared today to identify capacity issues and/or data-reporting issues for purpose of generating a potential solution.

12. Texas Council
Workgroup Updates

13. IDD Nursing Subcommittee
The Provider-Oriented Workgroup (POW) recommended forming an IDD Nursing Subcommittee.
Purpose: To develop best practices for all Community Centers related to IDD Nursing Services with a focus on billing procedures, continuum of care practices that will improve the quality of services and maximize billing, and strategies regarding Implementation Plans.
Membership: POW and Nursing Leadership Workgroup partnered to form the IDD Nursing Subcommittee, which is comprised of Directors of IDD Provider Services, Directors of Nursing, Registered Nurses, program coordinators, and billing specialists.
The IDD Nursing Subcommittee will function under the jurisdiction of the POW.

14. Provider-Oriented Workgroup (POW)
Purpose: Focus on provider-related functions
Projects: IDD Nursing, Direct Service Worker Training, Employment, EVV, Trauma-Informed Care
Potential Nominees: Provider Services Directors, including new directors
Local Authority Workgroup (LAW)
Purpose: Focus on authority-related functions
Projects: IDD Authority Handbook Review, Billing Guidelines Review (TCM PASRR, etc.), NCQA, Performance Contract Changes, HHSC rule-making and forms review
Both are set up to be think tanks/focus groups for specific (i.e. provider or authority) functions.
Typically meet the first Wednesday and Thursday of the month.
Other POW projects: Waiver Survey and Certification issues

15. Contact: icasas@txcouncil.com
Questions?
Contact:

16. Healthcare Policy Update
Presented to Texas Council Consortia
January 2019

17. State Legislative Activity
Post-DRSIP Landscape
Electronic Visit Verification (EVV)
CMS Managed Care Rules
HCBS Settings Statewide Transition Plan
Federal Initiatives
IDD Managed Care Pilot/Demonstration (Anticipated Legislation)
Senate Health and Human Services Interim Report
State Legislative Activity
2019 Managed Care Summit
NCQA LTSS Case Management Accreditation
Medication Adherence and Depression Tracking Texting Program
Texas Council and National Council Initiatives
UMCC Updates
Managed Care Procurements
TAC Revisions
State Contracting, Regulatory, and Rulemaking Activity
PASRR Litigation
Constitutional Challenges to the ACA
Legal Landscape

18. Federal Initiatives

19. Post-DSRIP Landscape DSRIP funding “cliff” is approaching (2021)
In August 2018, the Executive Directors Consortium unanimously approved Texas Council’s Adult Mental Health (AMH) 1115 Waiver Amendment proposal:
1. Tailoring the STAR+PLUS program to better meet the needs of adults with Serious Mental Illness (SMI) through value-based, directed payments, quality metrics specific to adults with SMI, and an increased emphasis and use of the Certified Community Behavioral Health Clinic (CCBHC) approach to care;
2. Creating an SMI target population with access to STAR+PLUS benefits; and
3. Establishing an Integrated Care Waiver Pool to maximize local and federal funding through the 1115 waiver to take integrated care for individuals with SMI to scale.

20. Electronic Visit Verification (EVV)
Directed by 21st Century Cures Act
States must implement EVV for all Medicaid personal care services (PCS) and home health services (HHCS) that require an in-home visit by a provider.
States must require EVV use for all Medicaid-funded PCS by January 1, 2020 and HHCS by January 1, 2023.
Otherwise, the state is subject to incremental FMAP reductions up to 1% unless the state has both made a “good faith effort” to comply and has encountered “unavoidable delays.” 

21. CMS Managed Care Final Rule Revisions
On November 14, 2018, CMS published proposed rules in the federal register related to Medicaid and CHIP managed care. The proposed rules adjust and build on the 2016 Final Rule or Mega Rule which provided the first comprehensive updates to Medicaid managed care rules since 2002.
Texas Council submitted/will submit feedback focused on changes to the regulatory framework likely to have downstream impact on Community Centers and Center clients.
CMS Managed Care Final Rule Revisions

22. HCBS Settings Statewide Transition Plan

23. State Legislative Activity

24. Transition to Managed Care
Transition of IDD LTSS continued focus.
HHSC shared interpretation of “protective provision:” in SB 7: only applies if all services transition. If a portion of services transition, enrollment in managed care is mandatory for all HCS, CLASS, and DBMD waiver enrollees for those services.
Texas Council wrote another “The Letter” sharing an alternative interpretation. HHSC’s response is pending.
TxHmL transition is being considered in the IDD SRAC and subcommittees. Evaluating each service separately.

25. Transition to Managed Care Timeline (select)
2014: STAR+PLUS
Medical services for individuals with IDD supported in HCS and TxHmL waivers and ICF rolled in to STAR+PLUS
2015: Community First Choice Implementation
2016: STAR Kids
Medical services for children with IDD and some LTSS (MDCP waiver) rolled in to STAR Kids
2020 (potential): LTSS for individuals in TxHmL Waiver to roll in to STAR+PLUS, STAR Health, and STAR Kids
2021 (potential): LTSS for individuals in HCS, ICF, and other waivers to roll in to STAR+PLUS, STAR Health, and STAR Kids
Transition to Managed Care Timeline (select)

26. IDD SRAC Recommends Delay
On July 17, 2018, the IDD System Redesign Advisory Committee voted to recommend delaying the transition of TxHmL services for at least three years and HCS, CLASS, DBMD, and ICF-IID services for at least seven years.
This is a recommendation only. The Legislature will need to amend existing law for current timelines to change.

27. IDD Managed Care Pilot/Demonstration
After the SRAC recommended delay, several legislators expressed interest in an IDD Pilot.
MCOs, led by United Healthcare and Molina, developed a proposal for an IDD Managed Care demonstration:
Services: LTSS services associated with the CLASS and TxHmL waivers today (e.g. respite, day habilitation, behavior supports)
Cohort: to a cohort of STAR+PLUS members with IDD currently on IDD Waiver Interest Lists.
The relationship among the proposed demonstration, the now cancelled IDD Managed Care Pilot, and the potential for a delayed timeline for any transition, continues to evolve.

28. Healthcare Legislation in the 86th Legislative Session
Medicaid Managed Care program design, oversight, and service delivery will be the subjects of focused legislative activity during the 86th Texas Legislative Session.

29. Senate Health and Human Services Interim Report
The Senate Health and Human Services Interim Report, which provides the legislative Committee’s recommendations for the upcoming Session, includes recommendations related to Medicaid:
quality
contract compliance

30. Recommendations: Medicaid Quality
directing the agency to hold MCOs financially accountable for not meeting quality metrics;
automatic enrollment to managed care plans based on quality if someone does not choose a managed care plan;
options for immediate enrollment into managed care;
better facilitation of data reporting, comparing, and sharing;

31. Recommendations: Medicaid Contract Compliance
continued utilization and expansion of contract enforcement mechanisms that better hold MCOs accountable;
continued focus on adequate networks, including maternal and behavioral health care;
reconfiguration and reduction in the number of managed care service delivery areas;
streamlining the complaints and appeals processes; and
institution of a clear and accountable Fair Hearings process, including the use of Independent Review Organizations (IRO) for cases of medical necessity.

32. Texas Council and National Council Initiatives

33. Managed Care Summit 2019
Building on the success of the first-annual Texas Council Managed Care Summit in March 2018, the Managed Care Steering Committee plans to offer the second-annual Managed Care Summit in Fall 2019 in order to incorporate legislative changes from the 86th Texas Legislative Session.
This Summit will be offered in conjunction with activities under the APM Development Project and will include a focus on Alternate Payment Methodology strategies that Community Centers can employ.

34. Texas Council, in collaboration with the Executive Directors Consortium, is exploring the possibility of Centers attaining case management accreditation to:
strengthen our standing in the shifting healthcare environment
potentially alleviate administrative burdens related to state audits of IDD TCM.
National Council on Quality Assurance LTSS Case Management Accreditation

35. National Council/Americares: medication adherence and depression tracking texting program
The National Council for Behavioral Health and Americares, a health-focused relief and development organization, are offering Texas Community Centers an opportunity to participate in a medication adherence and depression tracking texting program.
The program was created in partnership with Epharmix, a technology platform that uses clinically-validated interventions to send text messages to patients to engage them in their own care and streamline provider workflows.
Through an application process, ten participating organizations in Texas will be selected to enroll 50 patients each with a diagnosis of depression into the texting program, which will combine daily medication reminders and adherence messaging with mood tracking, depressive system tracking, and provider alerts over the course of 12 months.
 The anticipated timeline for this program is:
February 22, 2019: Application deadline 
Mid-March 2019: 10 organizations selected and announced
April 2019: Platform implementation and training with Epharmix 
May 2019: Patients begin to be enrolled in 12-month texting program

36. State Contracting, Regulatory, and Rulemaking Activity

37. HHSC staff informed Texas Council that, effective from the September 2018 update, the Uniform Managed Care Contract (UMCC) will be updated once annually (September), rather than twice-yearly (April, September).
The next update to the UMCC is anticipated in September 2019.
UMCC Changes

38. Managed Care Procurements
September 2020 – all STAR, and CHIP Service Areas
June 2020 – all STAR+PLUS Service Areas
September 2020– all Medicaid and CHIP Dental Service Areas
Managed Care Procurements

39. TAC Rule Changes
November 2018: Texas Council submitted written feedback on proposed changes to Texas Administrative Code (TAC) requirements around expedited credentialing.
Proposed new § requires an MCO, upon submission by the applicant of the information required by the MCO, to treat a qualified applicant provider as though the applicant is part of the MCO's provider network for purposes of Medicaid reimbursement.
Texas Council recommended HHSC add two provider types to the proposed provider types identified as eligible for expedited credentialing: Advanced Practice Registered Nurses (APRNs) and Physician Assistants (PAs). 
The proposed rules require an MCO to treat a qualified applicant provider as though the applicant is part of the MCO's provider network for purposes of Medicaid reimbursement “on submission by the applicant provider” of the information required by the MCO (emphasis added).
Texas Council will continue to monitor these proposed rules as they make their way toward finalization and implementation.

40. Legal Landscape

41. Constitutional Challenges to the Affordable Care Act
PASRR Federal Lawsuit
Constitutional Challenges to the Affordable Care Act
Legal Landscape